Parenting Resilient Kids (PaRK), an online parenting program to prevent anxiety and depression problems in primary school-aged children: Study protocol for a randomised controlled trial

Depression and anxiety disorders tend to start early in life and give rise to a cascade of negative long-term consequences. A meta-analysis of the age of onset for anxiety disorders shows that separation anxiety and specific phobia show an age of onset from 10 to 11 years indicating that primary school years could be a significant risk phase for developing anxiety disorders [1]. Longitudinal studies have found a significant association between early-onset anxiety disorders and later risk of anxiety and depressive disorders in adulthood, nicotine, alcohol and illicit drug dependence, under-achievement in education, and early parenthood [2]. The recurrence of depressive disorders in adulthood following a childhood episode of major depressive disorder has been estimated to be as high as 75% [3]. Therefore, preventive efforts targeting childhood anxiety and depression syptoms have the potential to alter the developmental trajectory of anxiety and depressive disorders across the lifespan.

Consideration of family and parenting factors in the prevention of depression and anxiety has been recognised as a key research translation priority [4‐6]. Yap and Jorm conducted a systematic review of the complex literature examining links between parental factors and depression or anxiety problems in children aged 5–11 [5]. They identified a range of modifiable parental factors, such as warmth, aversiveness and over-involvement, which were associated with childhood depressive symptoms, anxiety symptoms, and internalizing problems. They also noted that some parenting factors, namely abuse, inter-parental conflict and over-involvement, have not been adequately incorporated into existing prevention and intervention programs. Therefore, there is a clearly identified need for translation of the evidence regarding risk and protective factors into specific, practical strategies that parents can use to reduce the risk of depression and anxiety in their children.

Parenting-focused preventative interventions have been found to reduce externalising and internalising problems as well as increase positive attributes such as self-regulation and self-esteem [7]. Yap et al. conducted a meta-analysis of randomised controlled trials (RCTs) of parenting interventions to prevent internalising problems in children and reported small but significant effects in reducing child internalising (including both depression and anxiety) problems in the longer term [8]. However, Morawska and Sanders argue that the capacity for preventative parenting interventions to produce valued outcomes is often compromised by poor parental engagement [9]. While perceived practical barriers, such as difficulties with accessibility (timing, frequency, location), have been shown to lead to poor engagement, using different delivery modalities and self-directed interventions has been shown to promote engagement [9].

Web-based programs reduce geographical and time constraints and can also be anonymous, potentially increasing engagement for individuals concerned about privacy, confidentiality, and stigma. Furthermore, online programs can be disseminated widely at low cost, making universal preventive efforts feasible. A meta-analysis of 12 web-based parenting programs showed statistically significant medium effects across parent and child outcomes, suggesting that parenting interventions can be delivered effectively using online platforms [10]. There is also considerable support for effectiveness of web-based prevention and intervention programs for child and adolescent anxiety and depression [11‐13]. Given the advantages of online delivery, and the success of online programs to date, the development of web-based preventive parenting interventions has been recommended as an important strategy to increase participation in preventive programs [14, 15].

The ‘Parenting Resilient Kids’ (PaRK) intervention is part of the broader Parenting Strategies program (www.​parentingstrateg​ies.​net), and modelled on two other existing web-based parenting interventions [16, 17]. It was developed as a web-based preventive parenting intervention for depression and anxiety in primary school-aged children. The content of the program is derived from the Parenting Guidelines ‘How to reduce your child’s risk of depression and clinical anxiety: strategies for parents of primary school-aged children’, which will be referred to as Guidelines hereafter [18]. The Guidelines were developed based on a systematic review of parental factors associated with anxiety, depression, and internalising problems in children aged 5–11, which parents can potentially modify [5], as well as a Delphi expert consensus study to translate the evidence into practical strategies. A recent online survey evaluation of the Guidelines supports their acceptability among both parents and professionals, and their dissemination as a universal resource for the prevention of childhood depression and anxiety [19]. Parents who intend to put the Guidelines into practice may require further support in identifying individual needs as well as in building skills in the domains identified in the Guidelines. To facilitate this process, an online parenting program was developed which includes: (a) an online self-assessment parenting scale, which provides a personalised feedback report; and (b) an interactive parenting program comprising up to 12 modules. Table 1 shows the Guidelines and the corresponding subsections of the parenting scale and module components.

The Parenting Resilient Kids program was also developed to fulfill many of the principles of persuasive systems design, a concept defined as “computerised software or information systems designed to reinforce, change or shape attitudes or behaviours [20]. A systematic review by Kelders and colleagues suggests that adherence to web-based interventions can be improved by incorporating persuasive technology elements into the design [21]. For example, persuasive design features of the program include tailoring (of feedback and parenting program), personalisation (the parenting program offers participants their own personalised dashboard, diary pages etc.) and self-monitoring (of progress through goals and modules).

The online parenting scale was developed to evaluate a wide range of potentially modifiable parenting practices against the 12 parenting domains covered in the Parenting Guidelines. This scale is a criterion-referenced measure that is modelled on two other published measures used in the existing Parenting Strategies interventions [22, 23]. Parents’ responses to the items in the parenting scale are used to determine the content of the individually tailored feedback report, which will be received by parents in the intervention group. To automate the personalisation of the feedback content, a system of scoring the scale responses was developed whereby algorithms were created for all possible combinations of responses on each parenting domain on the scale. The algorithms link each possible combination of scale responses to the corresponding feedback messages that are appropriate to the responses selected and the score obtained for the parenting domain. The resulting personalised feedback report highlights individual strengths and areas for improvement in the different parenting domains. Where relevant, links are provided for parents to seek additional information from external websites if they wish. The feedback messages are designed to be brief and provide an overview of the parenting modules to encourage parents seeking further information to refer to the modules. The content of the scale and feedback messages were initially drafted by a doctoral student with postgraduate qualifications in psychology (WHS) and evaluated by the research team (comprising WHS, MBHY, AFJ, KAL) to ensure their fidelity to the Guidelines.

The web-based parenting program consists of 12 modules carefully selected to encompass the content of the Guidelines. Table 1 outlines the module titles and rationale for including each module. The modules are presented in a conversational tone and are designed to be engaging, informative and interactive. Each module includes illustrations, tasks designed to help parents troubleshoot parenting challenges, vignettes, interactive tasks that provide further practice for skills learnt in the modules, goal-setting tasks and an end-of-module quiz with immediate feedback. Module content was initially drafted by a doctoral student with graduate qualifications in psychology (LMNF) and evaluated by the research team (comprising LMNF, MBHY, AFJ, and KAL) to ensure their fidelity to the Guidelines as well as to other relevant evidence and credible resources.

Target end-users (parents of primary school-aged children) were invited to co-design the program by participating in reference groups. Fourteen parents of primary school-aged children (5–11 years) were recruited via staff newsletters across Monash University and the University of Melbourne. Parents participated in a 2-hour workshop in which they reviewed the text of the parenting scale and a mock feedback report, focusing on the acceptability of the language, and the logic of the feedback messages. Parents also reviewed two modules for language, tone, degree of interactivity and density of content. Parents who had agreed to be contacted on an ad hoc basis following the workshop, were consulted regarding the design and layout of the registration website and online scales, the usefulness of feedback messages generated from the parenting scale, and as well as content and presentation of modules.

This RCT will compare the effects of providing parents with the Parenting Resilient Kids program (intervention) to a standardised package of educational factsheets about child development and wellbeing.

Specifically, we hypothesise that:

Previous research suggests that parents can play a critical role in the prevention of anxiety and depressive disorders in their children. The Parenting Resilient Kids Program was developed as a web-based parenting intervention for parents of children aged 5–11 and was designed to be practical and parent-friendly, yet firmly rooted in research evidence. This RCT will examine whether compared to providing parents with a standardised package of educational factsheets, the Parenting Resilient Kids program leads to changes in parenting factors that are important in preventing child depression and anxiety in the short term (3 months after baseline), and child depressive and anxiety symptoms in the medium term (12 months post-intervention) and longer term (24 months post intervention). The RCT will also examine whether, compared to the control group, parents who have received the Parenting Resilient Kids intervention would show significant changes in children’s and parents’ health-related quality of life. If the Parenting Resilient Kids intervention is found to be effective, it can then be disseminated widely as a cost-effective preventative parenting program leading to better mental health and quality of life outcomes for primary school-aged children. This carries the potential to alter the developmental trajectory of anxiety and depressive disorders across the lifespan. Findings from this study may also contribute to the knowledge base for designing effective web-based prevention programs for parents and the extent to which parents can be engaged and motivated to change through a minimally guided parenting program.

This trial is currently recruiting participants till end of March 2018. A total of 1894 primary schools were contacted across Australia, of which 358 agreed to advertise the study. To date, the study has recruited 321 parent-child dyads, which is 94% of the required sample. The first participant was enrolled on 8 March 2017.